For discussion and debate about the ethics of health care organizations and the wider health system.

Sunday, July 27, 2008

Conflict of Interest in the American Psychiatric Association

Today I experienced the impact of conflict of interest on trust first hand. Sadly, it involves the professional society I have belonged to for 40 years - the American Psychaitric Association (APA).

The July 18 issue of the APA newspaper "Psychiatric News" has a column about conflict of interest and transparency by APA president Nada Stotland. Dr. Stotland comments that "for reasons that are unclear, much of the [media] attention [to conflict of interest in medicine] has focused on psychiatrists and APA..."

Sadly, the reasons are all too clear. Psychiatry has become so strongly biologically oriented that the profession is in danger of losing the respect it has earned as the most humane of specialties. We have experienced recurrent backtracking on the safety and efficacy of psychiatric medications. The degree to which the pharmaceutical industry supports the APA (30% of revenues) and individual leaders in the field has been widely publicized.

Dr. Stotland's column acknowledges the danger that that "the receipt of money or gifts causes our patients and the public to question our professional integrity - and [potentially] undermines the credibility of everything we do." She cites APA policies about disclosure of commercial relationships and the limits set on Pharma income ($10,000) for participants on key committees, and concludes "I believe we are doing what we can..."

A story on the next page in "Psychiatric News" described an APA resolution presented to the AMA House of Delegates asking for reexamination of the FDA criteria for approving generic medications for bio-equivalence. In her testimony at the AMA Dr. Stotland acknowledged "that at a time when organized medicine is under public scrutiny regarding ties to the pharmaceutical industry, a resolution raising questions about the clinical efficacy of some generics would raise skepticism in some quarters."

I admire Dr. Stotland and I love the APA, but my own reaction was just what she predicted for "some quarters." If loyal 40 year members of the APA feel something between queasiness and shame on the issue, imagine the reaction of those with less trust in the Association and its leadership!

The corrosive impact of conflicts of interest occur not only through actual distortions of judgment, but also through loss of trust in individuals and groups. The APA is at severe risk for losing trust. The problem will only get worse, given the intense scrutiny of the incoming APA president's relationship to a pharmaceutical company. (See, for example, a series of postings on the Health Care Renewal blog.)

Even if our confidence in our own integrity is 100% warranted, we can't expect even the most fair-minded persons to rest easy if it is disclosed that we have stock holdings worth millions in a company whose drug we are studying. (This is what appears to be the case for the incoming APA president.) And if 30% of our budget comes from the manufacturers of branded medications, who is going to trust that our questioning of the bio-equivalence of generics - however justified it might be - rests on scientific and clinical concerns alone?

As I was writing this posting, Bob Dylan's "The Times they are A-Changin" started playing in my mind:

Come gather 'round peopleWherever you roamAnd admit that the watersAround you have grownAnd accept it that soonYou'll be drenched to the bone.If your time to youIs worth savin'Then you better start swimmin'Or you'll sink like a stoneFor the times they are a-changin'.

I don't see any easy answers to the quandary the APA is in. But the status quo with a sprinkling of disclosure will not sustain the trust my profession needs. With regard to the relationship between medicine and the industries that produce pharmaceuticals and devices, the times are definitely changing!

About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.